Is public health getting to grips with problem gambling in Scotland?

As a public health professional in Scotland, I find myself increasingly concerned about the far-reaching impacts of problem gambling on individuals and communities.

When we talk about problem gambling, we must be clear that we're not merely discussing a recreational activity going too far. It is a complex issue that extends far beyond the narratives of personal choice and individual weakness among gamblers – intertwining as it does with socioeconomic disparities, mental health issues, age, gender, and the broader fabric of public health. We're confronting a multifaceted commercial determinant of health issue that can exact a devastating toll on individuals and their loved ones, and the odds appear stacked against specific groups and communities.

Advances in public health analytics and practice have contributed to a rapidly growing recognition of the role of commercial actors as powerful determinants of people’s health, safety and wellbeing across the planet. The World Health Organisation recently called for concerted action in this area, recognising that for too long, the ways that commercial practices and products threaten and undermine public health policymaking and targets have not received the attention they demand. The WHO endorses that applying a new commercial determinants lens to the pressing public health issues of our time is urgently needed to prevent unnecessary harm and health inequities.

The 2024 WHO publication “Commercial determinants of noncommunicable diseases in the WHO European Region”(¹⁾ does not include problem gambling as one of its commercial determinants case studies. However, as I will discuss, we can be certain that problem gambling is a commercial determinant of health and its adverse impacts to the health and wellbeing of affected populations is hugely concerning – resulting in the worsening of socioeconomic health inequalities.

The UK public spent £14.1 billion of their money within the gambling industry in 2021-22. Within Scotland, we see that gambling premises are concentrated in our most deprived communities. This means that those who are least able to afford the monetary losses face the greatest exposure to gambling and thus, gambling, specifically problem gambling, plays a part in health inequalities.

The impacts of problem gambling on young men are alarming. The addictive qualities of gambling coupled with cultural norms, peer pressures, risk- and thrill-seeking behaviours, and ever-increasing levels of accessibility through online channels, mean that a fun pastime can rapidly morph into a downward spiral of financial ruin, leaving young men drowning in debt and despair. Moreover, the psychological distress inflicted by problem gambling can lead to severe mental health consequences, including depression and anxiety disorders(2). Tragically, for some young people, men in particular, this psychological burden culminates in suicidality(3).

Problem gambling at age 20 has been associated with regular cigarette smoking, high levels of illicit-drug use, and problematic use of alcohol(4). This perhaps demonstrates the relationship between the psychological strain of problem gambling and unhealthy coping mechanisms, and/or the existence of co-dependencies within an overall toxic mental health environment, that some young people experience.  

In some instances, problem gambling has also been related to vulnerable populations, with those on low incomes and precarious job situations being disproportionately affected(5). The addictive nature of gambling can sometimes be related to the optimism of a quick financial fix made possible by a win, which is marketed by betting companies as tantalizingly within reach. Of course, what begins as a fleeting hope often ends in deeper financial woes and psychological turmoil, exacerbating the very hardships they sought to escape(6). Indeed, recent research by YouGov and GamCare shows how the cost-of-living crisis is exacerbating the harm from problem gambling, with betting shops being used as warm banks and people on Universal Credit and disability benefits using gambling as a means to try to make additional money to cover their bills.

So, has problem gambling been given the priority it deserves within public health policy making and research? I think the issue is becoming more recognised, as is the scale of what needs to be done to reduce its harms on the population. The profile of problem gambling within public health has been hindered by the very little data collected routinely, which means that understanding of the extent of the problem in Scotland is limited. This relates not only to individual problem gamblers but also those ‘at risk’ and those indirectly affected, such as family members. I really value the leadership and perspectives of Dr Michelle Gillies who has so effectively brought a much needed public health lens to problem gambling over the past five years. This has perhaps galvanised colleagues at Public Health Scotland, Cope Scotland and locally, Glasgow City Council, among many others, in recognising the need for a “Whole Systems Approach” (WSA) to tackling the adverse impacts of problem gambling.

A WSA to reducing problem gambling and mitigating its adverse impacts acknowledges the interconnected factors associated with it and seeks to address these comprehensively, rather than focusing solely on individual choice and behaviour. A WSA would involve multi-level interventions which consider the broader socio-environmental context, providing early intervention for individuals for treatment and support, and implementing evidence-based policies to regulate gambling activities. It would also provide education, prevention and awareness campaigns, and engage and support communities in addressing their specific gambling-related harms.

WSA are essential in reducing specifically the burden of problem gambling locally. In broader terms, the WHO recommends an overarching policy framework which aims to mitigate the impacts of commercial determinants related to the rising noncommunicable disease burden across Europe. The WHO calls for governments, civil society and academia to action, by building coalitions, emphasizing wellbeing and developing a clear commercial determinants policy agenda based on the core values of equity, sustainability, and resilience.

A question I always return to, however, is “What responsibilities do betting companies themselves have in preventing people becoming problem gamblers?". Well, thinking specifically about the exponential growth in the usage of online betting apps and platforms among young men, many gambling apps have introduced various measures such as ‘deposit caps’ and ‘cooling-off periods’ which are intended to support gamblers who ‘chase losses’ and demonstrate addictive tendencies. These approaches, however, rely entirely upon individuals experiencing problem gambling opting-in to the measures, and suddenly (and miraculously!) demonstrating non-addictive control and financial discipline. We know from several public health perspectives that such opt-in approaches are unlikely to engage effectively with the at-risk population and will not yield the types of impacts required.

In reality, when using an online betting app, such measures can be skipped within a second, the user proceeding immediately to today’s suite of tailored special betting offers and increased odds promotions. The impacts of such approaches in reducing the rates of problem gambling are questionable, to say the least. In the same way that alcoholic drinks companies profit from both responsible and problem drinkers, betting companies make billions of pounds in the UK from both responsible and problem gamblers.

Problem gambling now stands as a critical public health concern demanding concerted, collaborative action. Responses must adopt a WSA or holistic strategies and a commitment to addressing the interconnected determinants of problem gambling. Early intervention and prevention are vital, predicated on stronger public health surveillance of problem gambling in order to target approaches, to successfully engage the worst affected population groups, including young people and specifically young men from disadvantaged areas.

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(1) Examples of noncommunicable disease include cardiovascular disease, cancer, hypertension, diabetes, depression and anxiety.

(2) Butler N, Quigg Z, Bates R, Sayle M, Ewart H. Gambling with your health: Associations between gambling problem severity and health risk behaviours, health and wellbeing. Journal of Gambling Studies. 2020 Jun;36:527-38.

(3) Wardle H, McManus S. Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online survey. The Lancet Public Health. 2021 Jan 1;6(1):e39-49.

(4) Emond A, Griffiths MD, Hollén L. Problem gambling in early adulthood: A population-based study. International Journal of Mental Health and Addiction. 2022 Apr;20(2):754-70.

(5) Hahmann T, Hamilton-Wright S, Ziegler C, Matheson FI. Problem gambling within the context of poverty: a scoping review. International Gambling Studies. 2021 May 4;21(2):183-219.

(6) Lloyd J, Nicklin LL, Rhodes SK, Hurst G. A qualitative study of gambling, deprivation and monetary motivations. International Gambling Studies. 2021 May 4;21(2):307-25.